Professional indemnity insurance IET members proposal form (IT)

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Agatha Shaw
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1 . Professional indemnity insurance IET members proposal form (IT) Instructions Please provide a full answer to every question. Please ensure that all answers are typewritten or printed in block letters within the spaces provided. A principal of the practice must sign and date this form and any separate sheets. 1 Name and address details Practice name (please include all names under which you practice) Main office address Telephone number Postcode: Contact address Employer s Reference Number (ERN) (found on PAYE documents) Practice website Date established List number of branch offices Please list on a separate sheet all branch offices including addresses for which you are seeking cover. Is cover required for anything other than work undertaken by the above firm(s)? This may include a predecessor in business or liability of one of your partners or principals relating to work undertaken elsewhere. If, please provide details: 2 The firm Please list below your details if you are a sole trader or those of the Partners / Directors / Members of the company. Name of all partners / directors / members Date of birth Qualifications Years in the industry How long as partner / director/ member of the firm(s) Please provide a C.V. outlining all relevant experience where any person(s) noted above have been working in the industry for less than 5 years Please advise number of: Partners / Directors / Members Support Personnel Managers Sales and Marketing Technical Personnel Other 3 Subcontractors Does the Company/Firm engage or intend engaging in the future any external sub consultants / sub contractors? Do you ensure they hold their own professional indemnity insurance? Bluefin Professions IET members (IT) v1.0

2 4 Gross fee turnover State the gross fees received for the following years Last Completed Financial Year Current Year Estimate Next Year 1. UK Law Contracts 2. EU Law Contracts 3. USA / Canada Law Contracts 4. Other Law Contracts Total Gross Fee Turnover Give details of the five largest contracts commenced during the past three years. If you are a new company, provide details of the largest contract(s) expected to start in the next 12 months. Client Name Clients Business Nature of Contract Contract Value Fees Received 5 Your business activity Are you responsible for, or do you provide advice in relation to any of the following: 1. Full project implementation of IT or other systems? 2. Mission critical systems? 3. Games Development? 4. Internet Service Provision (ISP services), Application Service Provision (ASP) or financial transaction web site design? 5. Fully outsourced or managed services? 6. Full implementation of Enterprise Resource Planning (ERP) or customer Relationship (CRM) systems? 7. Financial live trading systems? 8. Manufacturing process control systems? 9. Hosting of e-commerce websites? 10. Specialist network security work including penetration testing? If to any of the above areas, please provide full details on a separate sheet of your services provided and describe in detail the 3 largest contracts you have been involved in.

3 Your turnover (including fee income) must be separated approximately into the activities listed below so that Insurers can understand what you are doing, in addition Insurers can only cover you for work that you declare. a) Hardware i) Sales of own brand ii) Distribution of other brands iii) Installation iv) Maintenance b) Software product sales i) Shrink wrapped / off the shelf software a) Third Party b) Own Written ii) Customisable software c) Software services * i) Installation including configuration ( code changes) ii) Customisation (including code changes) iii) Developing bespoke applications iv) Maintenance d) Services i) Consultancy ii) Provision of contract staff iii) Provision of outsourced applications iv) Provision of managed services v) Training e) Internet services i) Web Design ii) Domain Name Registration ** iii) Web Hosting *** f) Others please specify

4 * How long is a typical software installation (including configuration and customisation services)? ** Do you only purchase domain names for customers if you are designing a website for that customer? Are procedures and diary systems in place to ensure that domain names are not allowed to lapse without your customers knowledge and consent? *** Do you use a third party to do all hosting? Is the failure of any of your products or services liable to result in any of the following outcomes, or do you work on any systems which could cause: 1. Loss of life or injury to a person? 2. Destruction or damage to physical property? 3. Significant financial loss? 6 Claims and circumstances 6.1 Has the Company/Firm suffered any loss or identified any potential loss during the past five years through fraud or dishonesty of any Employee, Director, Member or Principal? If, state date, circumstances, amount and steps taken to prevent recurrence. 6.2 Have any claims in respect of liabilities to be covered by the proposed insurance (successful or otherwise) been made against the Company/Firm or its present and/or past Partners, Directors, Members? If, give full details including amounts involved. Have all claims been notified to Insurers? What measures have been taken to prevent a recurrence of the situation which gave rise to any claim? 6.3 Are any of the Partners, Directors or Members or employees AFTER ENQUIRY, aware of any circumstances, allegations or incidents which may give rise to a claim against the Firm(s) or its predecessors in business or any of its present or former Partners, Directors or Members? If, give full details of circumstances and amounts involved. 7 Current insurance Do you currently have professional indemnity insurance? If, please provide details Renewal date Insurer Broker Limit of indemnity any one claim / aggregate please advise Excess Premium

5 Has any proposal for professional indemnity insurance ever been declined by an insurer to whom you have applied? If, please provide details 8 Future requirements Please advise your requirements Option 1 Option 2 Option 3 Limit of indemnity Excess Confirmation Disclosure of material facts It is essential that every Proposer or Insured when seeking a quotation, taking out or renewing an insurance, reveals to the prospective Insurers any material facts or information (including any material circumstances or change in circumstance) which might influence the judgement of Insurers in fixing the premium or in determining whether they will accept the risk. Failure to do so may render the contract of insurance voidable from inception at the option of the Insurers and enable them to repudiate liability thereunder. If you have any doubt as to what constitutes a material fact or circumstance, seek our advice. I declare that the above statements and particulars are true, full enquiry having been made, and I have not omitted, suppressed or misstated any material facts and undertake to inform the Insurer of any change to any material fact. I understand that the information provided will be used by the insurers and/or their agents to arrange and administer the insurance and in handling claims which may necessitate sharing information with third parties and that information may be shared with business partners to deliver any additional services provided with this insurance. I further agree that this declaration, together with any other information provided shall be the basis of any contract between me and the Insurer. A copy of this proposal should be retained by you for your own records This form must be signed by a principal of the firm Signature: Date: Print name: Position: Please return this application form along with any other supplementary information sheets to the address detailed below:- Bluefin Professions Castlemead Lower Castle Street Bristol BS1 3AG t: f: e: enquiry.professions@bluefingroup.co.uk Bluefin Professions is a trading name of Bluefin Insurance Services Limited which is authorised and regulated by the Financial Conduct Authority. Registered Office: 5 Old Broad Street, London EC2N 1AD. Registered in England : Bluefin Insurance Services Limited

Professional indemnity insurance Management consultants proposal form

Professional indemnity insurance Management consultants proposal form Instructions Please provide a full answer to every question. Please ensure that all answers are typewritten or printed in block letters